Naresh T. Gunaratnam

Unsuspected infection is infrequent in asymptomatic outpatients with refractory ascites undergoing therapeutic paracentesis

Objective:Large-volume paracentesis is a safe and effective means of treating patients with refractory ascites. However, there is limited information regarding the need for ascitic fluid studies in asymptomatic outpatients presenting for therapeutic paracentesis. The aim of this prospective study was to define the incidence and natural history of peritoneal fluid infection in asymptomatic outpatients undergoing therapeutic paracentesis.Methods:Over a 13-month period, 118 therapeutic paracenteses were performed in 29 outpatients with decompensated cirrhosis (Child-Pugh class B = 38%, C = 62%). After a brief medical history and physical examination, ascitic fluid cell count with differential and culture were obtained from all participating subjects. Seven (24%) of the subjects were receiving norfloxacin prophylaxis, accounting for antibiotic coverage during 40% of the procedures performed. The clinical course and outcome of study subjects during a mean follow-up of 137 days was reviewed.Results:All 118 (100%) of the ascitic fluid samples demonstrated absolute neutrophil counts of <250/mm3 (mean = 6.5 ± 22.5 pmn/mm3). Asymptomatic bacterascites was identified from three of the 118 (2.5%) fluid samples, but all of these subjects spontaneously recovered without treatment or sequelae. During follow-up, six episodes of symptomatic or hospital-associated peritoneal fluid infection were identified in study participants, emphasizing the importance of fluid studies in other clinical settings.Conclusion:Although further studies are needed, the routine culture of ascitic fluid in asymptomatic outpatients with refractory ascites requiring therapeutic paracentesis may not be necessary when there is a low index of suspicion for occult infection. In circumstances of clinical uncertainty, however, obtaining ascitic fluid cell counts with differential is recommended to insure patient safety.

Optical biopsy of sessile serrated adenomas: do these lesions resemble hyperplastic polyps under narrow-band imaging?

BACKGROUND Serrated colorectal lesions include hyperplastic polyps (HPs) and sessile serrated adenomas (SSAs). Optical biopsy could misclassify SSAs as unimportant if they resemble HPs. OBJECTIVE To explore the narrow-band imaging (NBI) features of SSAs. We hypothesized that SSAs resemble HPs under NBI. DESIGN Retrospective analysis of data from our prospective study of NBI in routine practice. SETTING Single specialty group. PATIENTS Patients undergoing colonoscopy. INTERVENTION Colonoscopy. MAIN OUTCOME MEASUREMENTS Polyp histology prediction by community gastroenterologists. Features of SSAs versus HPs and adenomas by using the Narrow-Band Imaging International Colorectal Endoscopic (NICE) Classification. RESULTS Among 2388 lesions, 141 were diagnosed on pathology as SSAs, 465 as HPs, and 1546 as adenomas. Each individual NICE feature of HPs was found in 38% to 42% of SSAs, 66% to 67% of HPs, and 15% to 20% of adenomas (P < .001 for each). Each individual NICE feature of adenomas was found in 57% to 62% of SSAs, 33% to 34% of HPs, and 80% to 84% of adenomas (P < .001 for each). Compared with HPs, SSAs were less likely (odds ratio [OR] 0.74; 95% confidence interval [CI], 0.69-0.79) and adenomas were even less likely (OR 0.62; 95% CI, 0.59-0.64) to have all 3 NICE features of HPs. SSAs >5 mm were more likely than smaller SSAs to have all 3 NICE features of adenomas. SSA location did not predict NBI features. Analyses restricted to high-confidence lesions showed similar results. LIMITATIONS The endoscopists were not NBI experts. CONCLUSION Community gastroenterologists observed a profile of NICE features among SSAs that was intermediate to the profiles observed for HPs and adenomas. These results require confirmation by NBI experts.

Helicobacter pylori-associated gastric MALT lymphoma in liver transplant recipients

Background. Immunosuppressed transplant recipients are at increased risk of developing several forms of malignancy. The aim of this study is to report the clinical presentation, treatment, and outcome of four liver transplant recipients with Helicobacter pylori–associated gastric mucosae-associated lymphoid tissue (MALT) lymphoma. Methods. The medical records of four liver transplant recipients with gastric MALT lymphoma were reviewed. In situ hybridization for Epstein-Barr–encoded ribonucleic acid was performed on formalin-fixed tissues. Results. All four subjects presented with abdominal symptoms at a mean of 6.1 years posttransplant. Ulcerative lesions biopsied at endoscopy demonstrated early-stage gastric MALT lymphoma with associated Helicobacter pylori gastritis. In situ hybridization revealed no evidence of Epstein-Barr virus infection in examined tissues. Antibiotic eradication of Helicobacter pylori lead to disease remission in three subjects with a mean follow-up of 21 months, and one subject failed to respond to antibiotics and radiation therapy and died from metastatic gastric adenocarcinoma. Conclusions. Early-stage, low-grade gastric MALT lymphoma that was associated with Helicobacter pylori gastritis responded to antibiotic therapy with a sustained clinical remission in three of four treated subjects. If other studies confirm a higher than expected incidence of gastric MALT lymphoma in immunosuppressed transplant recipients with Helicobacter pylori infection, screening and treating Helicobacter pylori infection in selected transplant patients may prove beneficial.

The utility of EUS-guided FNA in the diagnosis of metastatic breast cancer to the esophagus and the mediastinum

BACKGROUND Breast cancer can metastasize to the esophagus and the mediastinum. EUS-guided FNA (EUS-FNA) is being used increasingly as a less invasive alternative to mediastinoscopy for procuring a tissue diagnosis of mediastinal disease and may be useful for the diagnosis of breast cancer metastatic to the esophagus and the mediastinum. METHODS Twelve women (age range 54-82 years) with a history of breast cancer presented with dysphagia or other symptoms between 1 and 15 years after initial diagnosis and treatment. CT and endoscopy with biopsies suggested a mediastinal mass or lymphadenopathy with extrinsic esophageal compression but failed to provide a tissue diagnosis. EUS-FNA was performed for diagnosis. RESULTS Cytologic evaluation of specimens obtained by EUS-FNA confirmed breast cancer metastases in 11 of 12 patients (91%). Recurrent disease was found in intramural masses and periesophageal lymph nodes. No complication resulted from any EUS-FNA procedure. CONCLUSIONS EUS-FNA is safe and effective for the diagnosis of breast cancer metastases to the esophagus and the mediastinum. EUS-FNA may be useful as a first-line method of evaluation when breast cancer metastasis to the esophagus and the mediastinum is suspected.

MiraLAX-Gatorade bowel prep versus GoLytely before screening colonoscopy: an endoscopic database study in a community hospital.

Background: Polyethylene glycol-3350 without electrolytes (MiraLAX; Schering-Plough Healthcare Products Inc.)+a carbohydrate-electrolyte solution (Gatorade; PepsiCo Inc.)+bisacodyl is frequently used for bowel cleansing, although limited data quantifies its efficacy and safety. No prior studies have assessed this in a community setting or with PM-only dosing, which is still used frequently. Aim: To compare the frequency of excellent/good/fair/poor bowel cleansing with PM-only dosing of MiraLAX-Gatorade-bisacodyl versus 4-liter GoLytely. Methods: This is a retrospective endoscopic database analysis of 50 years and older average-risk individuals with a normal screening colonoscopy at a community hospital and ambulatory endoscopy center. Data were extracted for the last 4 months when 4-liter GoLytely was the preferred bowel purgative and the first 4 months when 238-g MiraLAX in 64-ounce Gatorade and four 5-mg bisacodyl tablets became the preferred purgative. All patients used PM-only dosing of bowel purgative. Results: A total of 778 subjects [GoLytely (n=395) vs. MiraLAX+Gatorade+bisacodyl (n=383)] were identified. Patients who took the MiraLAX bowel preparation were more likely to achieve an excellent/good bowel cleansing compared with patients taking the GoLytely preparation (93.3% vs. 89.3%, respectively; P=0.048). However, when only American Society of Anesthesiology (ASA) class I patients are studied, there was no difference in frequency of excellent/good bowel cleansing (91.1% vs 93.6%, respectively; P=0.498). No serious adverse events were identified. An excellent/good bowel cleansing was strongly associated with a recommendation for repeat colonoscopy in 10 years compared with patients with a fair cleansing (odds ratio=28.01; 95% confidence interval, 13.96-56.19). Conclusions: The MiraLAX+Gatorade+bisacodyl combination produces similar rates of excellent/good bowel cleansing as compared with GoLytely in most average-risk individuals undergoing colonoscopy for colorectal screening in a community setting.

Sa2074 Title: Successful Treatment of Refractory Clostridium difficile Infection(Cdi) With Intestinal Microbiota Transplant (IMT) in Two Patients With Inflammatory Bowel Disease (IBD) and Its Effects on IBD

C. difficile is responsible for 15-25% of antibiotic associated diarrhea and overall incidence of CDI is increasing including in patients with IBD. Among the various therapeutic modalities used for the treatment of IBD, only the use of steroids is found to be associated with increased risk of CDI; however the role of immunosuppressant use is controversial and the use of biologics has not been shown to have a clear association with development of CDI. Physicians are often reluctant to use immunosupression in the setting of CDI given fear of exacerbation of CDI, which in turn results in poor control of IBD. IMT has been demonstrated to be an effective treatment for refractory CDI. Methods: A 27-year-old woman with Crohns ileocolitis and refractory CDI for over one year had failed multiple prolonged tapering courses of vancomycin and probiotics. She had endoscopically proven active ileocolonic Crohns disease, which was not aggressively treated with immunosuppressants given her CDI. She had up to 25 stools a day and had lost 25 pounds, therefore she underwent successful IMT with approximately 250 g of donor stool from her mother, which was placed endoscopically into her ileum. Her diarrhea improved but did not completely resolve despite negative stool cultures two weeks post procedure. She was started on prednisone 40 mg a day, which was slowly tapered and started on Adalimumab concomitantly. She has been in clinical remission for over a year on 40 mg Adalimumab alone without recurrent CDI. A 39 yr old male with history of Ulcerative colitis diagnosed 15 ys ago with concomitant refractory CDI. He had been treated for CDI over 12 times in 15 years with multiple courses of flagyl, oral vancomycin and Rifaximin with no improvement. He continued to have 15 bowel movements per day. He was unable to tolerate adalimumab and azothioprine in the past and was felt to be high risk for steroids secondary to CDI. He underwent successful IMT on 2/2011 with donor stool from his mother. He has improved significantly since then and was started on high dose prednisone after negative C difficile testing with improvement of diarrhea. He has not had any relapse of CDI but still has evidence of active IBD on sigmoidoscopy five months post IMT. He has been maintained on 5 ASA drugs and a tapering course of steroids and being considered for colectomy. IMT with ileal infusion of the bacteriotherapy should be considered for treatment of refractory CDI in patients with concomitant IBD since it provides an opportunity to maximize therapy for IBD. A published case series of 6 patients demonstrated complete resolution of ulcerative colitis after IMT. Contrary to their study our experience with 2 patients showed resolution of CDI but no change in IBD with up to 1 year follow up. Further studies are needed to assess the role of IMT in the treatment of IBD.

Management of Clostridium difficile Infection : Survey of Practices and Compliance with National Guidelines Among Primary Care Physicians

Guidelines Among Primary Care Physicians • Author(s): Gayle L. Byker, MD; Marie T. Dinh, MD; Naresh T. Gunaratnam, MD; Eileen A. Robinson, MPH; Thomas M. Shehab, MD; Anurag N. Malani, MD Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 4 (April 2009), pp. 397-399 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/596200 . Accessed: 14/05/2014 19:20

A randomized, controlled trial to assess a novel colorectal cancer screening strategy: the conversion strategy

OBJECTIVE:Our study was a randomized, controlled trial to assess a novel strategy that provides comprehensive colorectal cancer screening in a single visit versus traditional sigmoidoscopy and, where appropriate, colonoscopy on a subsequent day.METHODS:Consecutive patients referred for screening were randomized to control or so-called “conversion” groups. Patients in the control group were prepared for sigmoidoscopy with oral phospho-soda. Those with an abnormal sigmoidoscopy were scheduled for colonoscopy on a future day after oral polyethylene glycol preparation. In the conversion group, patients were prepared with oral phospho-soda. Patients with a polyp >5 mm or multiple diminutive polyps were converted from sigmoidoscopy to colonoscopy, allowing comprehensive screening in a single visit. Clinical outcomes were assessed by postprocedure physician and patient questionnaires.RESULTS:Two hundred thirty-five patients were randomized (control = 121, conversion = 114). In the control group, 28% had an indication for colonoscopy. Three of 33 (9%) with an abnormal sigmoidoscopy did not return for colonoscopy. At colonoscopy, 27% had a proximal adenoma. In the conversion group, 28% had an abnormal sigmoidoscopy and underwent conversion to colonoscopy. Forty-one percent undergoing colonoscopy in the conversion group had a proximal adenoma. Physicians reported no differences in preparation or procedure difficulty, whereas patients reported no differences in the level of comfort or overall satisfaction between groups. When queried regarding preferences for future screening, 96% chose the conversion strategy.CONCLUSIONS:The conversion strategy led to similar outcomes compared to traditional screening while improving compliance with colonoscopy in patients with an abnormal sigmoidoscopy.

Screening for Cancer Genetic Syndromes With a Simple Risk-Assessment Tool in a Community-Based Open-Access Colonoscopy Practice

Screening for Cancer Genetic Syndromes With a Simple Risk-Assessment Tool in a Community-Based Open-Access Colonoscopy Practice